[1]Recreational water activities are a great way for people to stay active and relax

Recreational water activities are a great way for people to stay active and relax. Owners and operators of pools and spas/hot tubs must be mindful of the potential health hazards, injuries, infections, and in extreme cases, death. The Lifesaving Society, a charitable organization working to prevent drowning and water-related injury, reported 297 and 293 water-related fatalities in Canada in 2016 and 2017, respectively.1 A total of 210 recreational-water-related deaths were recorded in Ontario for the same period.

Water contamination and diseases

Recreational water facilities include pools, spas, wading pools, and splash pads. These facilities are subject to microbial contamination because bathers can introduce disease-causing germs such as bacteria, viruses, parasites, and fungi into the water.

Further, warm temperatures and rapid water turbulences in spas provide ideal conditions for germs to grow and multiply, leading to the spread of ailments like Legionnaires’ disease. Many disease outbreaks, such as cryptosporidiosis,2 pseudomonas, human enteric viruses (adenovirus, enterovirus),3 and fungal skin infections, such as athlete’s foot, can originate from pools, spas, and wading pools. These diseases are often transmitted when otherwise healthy bathers accidentally swallow contaminated water, inhale tainted mist droplets, or come in direct contact with dirty surfaces. Young children, the elderly, and those with weak immune systems are most likely at risk when exposed to harmful germs.

Pool hazards

[2]Vacuum release mechanism installed before the pump on the pipe that brings back water from the pool. If vacuum is detected, this safety mechanism is designed to allow air into the pipe and release the vacuum to prevent injury.

A malfunctioning filtration system and inadequate disinfection methods can cause microbes to grow and multiply quickly. In the recent past, failing/faulty equipment has caused occupational injuries to workers and resulted in serious harm to bathers due to chlorine inhalation. Not long ago, the release of chlorine gas in a pool enclosure resulted in one serious injury and evacuation of the facility.4

Water features like powerful pumps, which are used for recirculating water through filtration systems, can be a source of serious injury. There are also a number of other potential health and safety hazards associated with recreational water facilities. For example, drownings can occur at any water depth and shallow water dives can result in serious debilitating head and spinal injuries, and even death.

Protecting public health

[3]A coroner’s inquiry in 2009 following a drowning, recommended the requirement for a buoyline in all unsupervised Class B pools where the slope exceeds eight per cent. This illustration shows where to install a buoyline.

The World Health Organization (WHO) recognizes the hazards present in recreational aquatic environments as a public health concern and has published a two-part guideline5 that is the basis of standards and regulations designed to control health risks associated with recreational waters. Indeed, countries across the world, including the federal, provincial, and state governments of Canada and the United States, have proactively regulated public aquatic facilities accordingly.

In Ontario, pool regulations and guidelines for spas and wading pools date back to mid-1900s and earlier. Under the Ontario Health Protection and Promotion Act (HPPA), local boards of health (BOH) are required to deliver public health programs and services. The ‘Safe Water Program’ standard aims to “prevent and reduce the burden of water-borne illnesses and injuries related to recreational water use.” The Recreational Water Protocol, 20186 provides BOHs direction on how to properly operationalize the requirements outlined in the standard. One such requirement for BOHs is to ensure aquatic facilities meet the regulated minimum health and safety standards as set out in the modernized Public Pool Regulation 565 and Recreational Camps Regulation 568.

Pools and spas have evolved since the 1940s when the regulations were last revised. Advances in technology and design concepts, among other things, have led to several innovations in the recreational water industry. Familiar definitions of aquatic environments have increasingly blurred and hybrids like swim spas have become more common.

Public Pool Regulation 565

[4]This is an example of the materials developed for pool operators in the Toronto Public Health’s Public Pool, Public Spa, and Class C Facility Operator’s Manual.

Design innovations combined with modern technologies—such as powerful pumps, disinfection systems, and filtration methods—have health and safety consequences, which were not common in the 1900s. Although periodic amendments to pool regulations addressed such emerging impacts, a comprehensive modernization of the recreational water regulations in Ontario was long overdue. On July 1, 2018, Ontario’s Ministry of Health and Long-Term Care (MOHLTC) modernized and enacted several public health regulations including the Public Pool Regulation 565 and the Recreational Camps Regulation 568. When updating the existing regulation, the Ministry’s primary aim was to develop a regulation that was streamlined, concise, user-friendly, and supported innovation. Further, the regulation intends to set clear expectations, is based on evidence and outcome, and most importantly, benefits public health and safety.

The process to modernize the regulation began in 2015. Various stakeholders such as industry and public health groups and inter-ministerial/governmental agencies were consulted. As a result of the consultation process, more than 100 recommendations were identified. The process was completed in December 2017, and the new pool regulation incorporated many recommendations from technical, scientific, and policy groups.

The modernized Public Pool Regulation 565 is fundamentally different from its predecessor. Previously, separate pool and spa regulations laid out requirements for the respective facility types. However, the new regulation merges the requirements of the previous two regulations. It extends minimum public safety and facility operational requirements (e.g. supervision, disinfection, safety equipment, and signage) to wading pools and splash pads that were previously non-regulated, recognizing these facilities also pose health and safety risks similar to public pools and spas.

[5]In 2015, Toronto Public Health (TPH) expanded public disclosure to public pool and spa inspections. The modernized regulation acknowledges the value of disclosure to public health and safety and, therefore; requires facility operators to post inspection results.

The previous spa regulation required every spa operator to be trained in operation and maintenance, filtration systems, water chemistry, and relevant safety and emergency procedures. This requirement is carried over to the new Public Pool Regulation 565 where it applies to pools. To support such training, the Recreational Water Protocol, 2018, requires local BOHs to make the following available:

Information and/or education materials to owners and operators regarding applicable regulations and operational procedures relevant to public recreational water facilities and camps.

Recreational water training program materials that include, but are not limited to:

○ applicable public health legislation and regulations;

○ prevention of illness, injury, or death;

○ water chemistry;

○ sanitary operation of amenities in the facility;

○ provision of safety equipment;

○ emergency communication and procedures;

○ safety supervision;

○ applicable admission standards; and

○ recordkeeping.

Coinciding with the enactment of the new Public Pool Regulation 565, the Chief Justice of Ontario established set fines for infractions under the legislation. Previously, for both the pool and spa regulations, the only option available to Public Health Inspectors (PHIs) was to issue a Part III Summons under the Ontario Provincial Offences Act (POA). However, with the new set fines, PHIs have flexibility in issuing tickets with set fines or a summons, based on a number of considerations.

Public disclosure

[6]The pool’s main drain covers (either side of the black disc) must be securely fastened and in good condition to prevent accidental entrapment. Also, the disc should be clearly visible from any point 9 m (29.6 ft) from the deck.

In spite of enforcement remedies available to public health units, historical evidence for compliance with various regulations, including public pools, spas, and food safety inspections indicated a persistently high level of non-compliance. To address this high rate of non-compliance, Toronto Public Health (TPH) first introduced public disclosure of restaurant inspection results in 2001. Since its implementation, in addition to achieving a substantial increase in compliance rate (with the regulation), many advantages of public disclosure have become evident. This kind of transparency empowers the public to make informed decisions before choosing to use a facility. It promotes public trust and significantly supports enforcement by creating a strong incentive for owners and operators to comply with applicable legislation.

Learning from this experience, in 2015, TPH expanded public disclosure to public pool and spa inspections. The modernized regulation acknowledges the value of disclosure to public health and safety and, therefore; requires facility operators to post inspection results. As such, TPH’s recreational water facility disclosure system aligns with the Recreational Water Protocol requiring public health units to disclose inspection results to the public.

Incorporating recommendations for safe aquatic activity

[7]The Public Pool Regulation 565 incorporates many requirements from the Model Aquatic Health Code (MAHC). It lists the minimum and maximum disinfectant concentration limits for pools, spas, and wading pools.

Based on scientific research and best practices, the Centers for Disease Control and Prevention (CDC) has developed the Model Aquatic Health Code (MAHC) to make swimming and other aquatic activity safer and healthier.7 The new Public Pool Regulation 565 incorporates many requirements from the MAHC. For example, the introduction of maximum disinfectant concentration was derived from the model code. Chemical disinfectants, such as chlorine and its products, are powerful oxidizing agents that destroy harmful microbes. Exposure to high concentrations of these chemicals and their byproducts in pools, spas, and wading pools can be harmful to human health as well as the environment. Operationally, chemically balanced water not only prevents corrosion and scaling-related damage to property, but it is also necessary for optimal disinfection power and, therefore, there is the need for lower and upper chemical concentration limits.

The modernized regulation has incorporated many recommendations made by the Office of the Chief Coroner for Ontario as well. A coroner’s inquiry in 2009 following a drowning, recommended the requirement for a buoyline in all unsupervised Class B pools where the slope exceeds eight per cent. The intent of the recommendation was to provide a lifeline to a distressed swimmer. Adopted by the Ontario Building code, this requirement is new to the Public Pool Regulation 565.

Additionally, the admission standards for public pools—another recommendation which is now included in the public pool regulations—requires the presence of a guardian (e.g. parent) or supervisor and a swim test for young children. The requirement intends to reduce the risk of drowning deaths and injuries by maintaining adequate surveillance over the whereabouts and the activities of young bathers while they are inside the pool enclosure. To achieve this, the regulation now requires Class A pool operators to have a mandatory process in place to ensure a guardian or designated person supervision of children less than 10 years of age. This process must include:

a swimming competency test for a child under 10; and

a method of communicating the requirements of the process (e.g. a wristband).

To establish this critical safety requirement, pool owners and operators should consult with water safety experts on best practices, such as standardized swim competency tests.

The regulation is now more flexible in recognizing lifeguard and assistant lifeguard qualifications. It acknowledges there are credible organizations, in addition to the Lifesaving Society, that train and certify lifeguards/assistant lifeguards. Organizations that wish to have their lifeguard/assistant lifeguard certification approved by MOHLTC can now apply directly to the ministry. To enable such approval, MOHLTC has developed an Ontario lifeguard and assistance lifeguard training standard based on currently accepted international and North American standards for which lifeguard training certificates will be evaluated to determine their acceptability.

Conclusion

Public health regulations, including the modernized Ontario Public Pool Regulation 565, are designed to protect public health and safety by establishing province-wide minimum standards. With the modernization process complete and the new pool regulation in place, the stage is set in Ontario for all stakeholders, including the recreational water industry and public health units, to work together to help make aquatic facilities healthy and safe. This is possible through ongoing collaboration between all parties involved in the modernization process and continued improvement of the regulation in tandem with the future evolution of the recreational water industry.

Notes:

1 See “Canadian Drowning Report 2018 edition,” prepared for the Lifesaving Society Canada by the Drowning Prevention Research Centre Canada. For more information, visit www.lifesavingsociety.com/media/291819/2018%20canadian%20drowning%20report%20-%20web.pdf. (Accessed on Oct. 16, 2019)

2 See “Cryptosporidium outbreaks associated with swimming pools,” by Steven Lam, Bhairavi Sivaramalingam, and Harshani Gangodawilage (all authors contributed equally to the paper), published on the web by Environmental Health Review on May 30, 2014. For more information, visit https://pubs.ciphi.ca/doi/full/10.5864/d2014-011. (Accessed on Oct. 16, 2019)

3 See “A Review and Update on Waterborne Viral Diseases Associated with Swimming Pools,” by Lucia Bonadonna and Giuseppina La Rosa, published online by the International Journal of Environmental Research and Public Health on Jan. 9, 2019. For more information, visit www.mdpi.com/1660-4601/16/2/166/htm. (Accessed on Oct. 16, 2019)

4 See “6 people injured after exposure to noxious fumes in Etobicoke,” posted by CBC News on May 17, 2014. For more information, visit www.cbc.ca/news/canada/
toronto/6-people-injured-after-exposure-to-noxious-fumes-in-etobicoke-1.2646518. (Accessed on Oct. 16, 2019)

5 See “Guidelines for Safe Recreational Water Environments,” published by World Health Organization in 2003. For more information, visit https://apps.who.int/iris/bitstream/handle/10665/42591/9241545801.pdf;jsessionid=1210B195237782D6FD32CCC043D963EF?sequence=1. (Accessed on Oct. 16, 2019)

6 See “Recreational Water Protocol, 2018,” published by the Population and Public Health Division, Ministry of Health and Long-Term Care (effective: January 1, 2018 or upon date of release). For more information, visit www.health.gov.on.ca/en/pro/programs/publichealth/oph_standards/docs/protocols_guidelines/Recreational_Water%20Protocol_2018_en.pdf. (Accessed on Oct. 16, 2019)

7 See the “2018 Model Aquatic Health Code & Annex,” published by the Centers for Disease Control and Prevention. For more information, visit www.cdc.gov/mahc/editions/index.html. (Accessed on Oct. 16, 2019)

[8]Mahesh Patel, CIPHI(C), is a health hazard manager with Toronto Public Health (TPH). He holds a M.Sc. in water environmental management, a B.Sc. (honours) in applied chemistry, and a BAA in environmental health. As the safe water lead, he is responsible for both drinking and recreational water quality. This includes monitoring drinking water, beach water, and the compliance inspection program for public pools, spas/hot tubs, and wading pools. As the legal and enforcement lead, Patel has played a major role in the development and implementation of policies and procedures. Internally he provides ongoing enforcement training and support to staff, while externally he continues to provide assistance and training to other Ontario health units and agencies for which he received an award of excellence from the Canadian Institute of Public Health Inspectors (CIPHI) in 2012. He can be reached via e-mail at mpatel@toronto.ca.